Documentation Specialist Jobs in New York
Documentation Specialist jobs in New York are consistently active, with strong demand across financial services, healthcare, legal, and technology sectors and openings at every level from entry-level coordinator through senior technical writer and compliance documentation manager. The heaviest hiring concentrates in New York City, Albany, and Buffalo, where large employers like Pfizer, JPMorgan Chase, and New York Presbyterian have long-standing documentation and regulatory affairs functions. The most in-demand specialties in New York are regulatory documentation, financial compliance records management, and clinical or pharmaceutical documentation. Find a role that fits below and apply directly.
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Showing 5 of 10+ Documentation Specialist jobs
Employment Type:
Full time
Shift:
Day Shift
Description:
RN Clinical Documentation Specialist
Full-time day shift
St. Peter's Hospital in Albany, NY
Position Highlights:
- Recognized leader: Magnet Hospital in the Capital Region
- Quality of Life: Where career opportunities and quality of life converge
- Advancement: Strong orientation program, generous tuition allowance and career development
What you will do:
The Clinical Documentation Specialist utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant. Facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review.
Through extensive interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients. Participates in the development and delivery of education for providers and members of the healthcare team.
PRIMARY JOB RESPONSIBILITIES AND DUTIES:
- Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, standards, policies, procedures and decisions.
- Demonstrates understanding of appropriate clinical documentation, to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record.
- Assists in overall quality, timeliness and completeness of the health record to ensure appropriate data, provider communication and quality outcomes.
- Serves as a resource for appropriate clinical documentation.
- Communicates with and educates physicians and all other members of the healthcare team regarding clinical documentation and monitors provider engagement.
- Identifies learning opportunities for healthcare providers.
- Conducts concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency and precision of clinical documentation.
- Formulates compliant clarifications/queries following Trinity Health’s documentation integrity procedures.
- Interacts with physicians, nurses and ancillary staff regarding compliant documentation requirements, clarification/query requests and educational opportunities.
- Accurately codes all relevant, appropriate and compliant working diagnoses codes, establishing a working principle diagnosis and working DRG (MS or APR).
- Collaborates with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care.
- Resolves all discrepancies in a courteous manner.
- Demonstrates expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgement and serves as a professional role model by demonstrating desirable practice behaviors.
- Proficient with leveraging the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness.
- Performs other duties as assigned by leadership.
- Maintains a working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies, Trinity Health’s Organizational Integrity Program, Standards of Conduct, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.
MINIMUM QUALIFICATIONS, REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:
Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) OR an Advanced degree in nursing or medical field such as NP/APN or PA.
Must possess one of the below:
- Current Registered Nurse License
- Registered Health Information Administrator (RHIA)
- Registered Health Information Technician (RHIT)
- Certified Coding Specialist (CCS) required
- Licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN) or completion of medical school.
Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred. Two (2) years experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate or as an inpatient coder preferred. Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills. Strong critical thinking skills and ability to integrate knowledge. Prioritization and organizational skills required. Effective presentation/facilitation skills to accomplish educational goals for all members of the healthcare team. Demonstrated ability to use a standard desktop and Windows based computer system, including a basic understanding of email, internet and computer navigation. Ability to use other software as required to perform the essential functions on the job. Experience with databases, spreadsheet software and presentation software preferred. Accurate data entry skills and typing skills at minimum 30 wpm. Must be comfortable operating independently and in a collaborative environment. Must possess a personal presence that is characterized by a sense of honesty, integrity and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals and values of Trinity Health.
PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS:
Must be able to set and organize own work priorities and adapt to them as they change frequently. Must be able to work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles. Must possess the ability to comply with Trinity Health policies and procedures. Must be able to spend majority of work time utilizing a computer, monitor and keyboard. Must be able to work with interruptions and perform detailed tasks. The position requires the ability to concentrate and read for long periods of time. Ability to work in an onsite and virtual environment.
REPORTING RELATIONSHIPS:
Reports directly to the Regional CDI Manager
Has no responsibility for the supervision of staff.
Pay Range: $31.50 - $47.97
Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location.
Our Commitment
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.
Employment Type:
Full time
Shift:
Day Shift
Description:
RN Clinical Documentation Specialist
Full-time day shift
St. Peter's Hospital in Albany, NY
Position Highlights:
- Recognized leader: Magnet Hospital in the Capital Region
- Quality of Life: Where career opportunities and quality of life converge
- Advancement: Strong orientation program, generous tuition allowance and career development
What you will do:
The Clinical Documentation Specialist utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant. Facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review.
Through extensive interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients. Participates in the development and delivery of education for providers and members of the healthcare team.
PRIMARY JOB RESPONSIBILITIES AND DUTIES:
- Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, standards, policies, procedures and decisions.
- Demonstrates understanding of appropriate clinical documentation, to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record.
- Assists in overall quality, timeliness and completeness of the health record to ensure appropriate data, provider communication and quality outcomes.
- Serves as a resource for appropriate clinical documentation.
- Communicates with and educates physicians and all other members of the healthcare team regarding clinical documentation and monitors provider engagement.
- Identifies learning opportunities for healthcare providers.
- Conducts concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency and precision of clinical documentation.
- Formulates compliant clarifications/queries following Trinity Health’s documentation integrity procedures.
- Interacts with physicians, nurses and ancillary staff regarding compliant documentation requirements, clarification/query requests and educational opportunities.
- Accurately codes all relevant, appropriate and compliant working diagnoses codes, establishing a working principle diagnosis and working DRG (MS or APR).
- Collaborates with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care.
- Resolves all discrepancies in a courteous manner.
- Demonstrates expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgement and serves as a professional role model by demonstrating desirable practice behaviors.
- Proficient with leveraging the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness.
- Performs other duties as assigned by leadership.
- Maintains a working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies, Trinity Health’s Organizational Integrity Program, Standards of Conduct, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.
MINIMUM QUALIFICATIONS, REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:
Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) OR an Advanced degree in nursing or medical field such as NP/APN or PA.
Must possess one of the below:
- Current Registered Nurse License
- Registered Health Information Administrator (RHIA)
- Registered Health Information Technician (RHIT)
- Certified Coding Specialist (CCS) required
- Licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN) or completion of medical school.
Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred. Two (2) years experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate or as an inpatient coder preferred. Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills. Strong critical thinking skills and ability to integrate knowledge. Prioritization and organizational skills required. Effective presentation/facilitation skills to accomplish educational goals for all members of the healthcare team. Demonstrated ability to use a standard desktop and Windows based computer system, including a basic understanding of email, internet and computer navigation. Ability to use other software as required to perform the essential functions on the job. Experience with databases, spreadsheet software and presentation software preferred. Accurate data entry skills and typing skills at minimum 30 wpm. Must be comfortable operating independently and in a collaborative environment. Must possess a personal presence that is characterized by a sense of honesty, integrity and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals and values of Trinity Health.
PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS:
Must be able to set and organize own work priorities and adapt to them as they change frequently. Must be able to work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles. Must possess the ability to comply with Trinity Health policies and procedures. Must be able to spend majority of work time utilizing a computer, monitor and keyboard. Must be able to work with interruptions and perform detailed tasks. The position requires the ability to concentrate and read for long periods of time. Ability to work in an onsite and virtual environment.
REPORTING RELATIONSHIPS:
Reports directly to the Regional CDI Manager
Has no responsibility for the supervision of staff.
Pay Range: $31.50 - $47.97
Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location.
Our Commitment
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.
See All 10 Documentation Specialist Jobs in New York
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Find Documentation Specialist JobsDocumentation Specialist Jobs by City in New York
Where New York roles are concentrated, by current openings.
Documentation Specialist Job Market in New York
A snapshot from current New York openings, updated as new roles post.
Who's Hiring
- Catholic Health1
- Catholic Health System1
- M&T Bank1
- NewYork-Presbyterian Hospital1
- Newark Wayne Community Hospital1
Top Industries Hiring
- Healthcare & Medical Services6
- Science & Research3
- Banking & Financial Services1
- Biotechnology & Pharmaceuticals1
- Education1
What New York Employers Look For
The qualifications that appear most often in documentation specialist jobs across New York.
- Bachelor's degree in English, communications, technical writing, or a related field
- Proficiency with documentation management systems such as Documentum or SharePoint
- Experience preparing regulatory submissions, SOPs, or compliance records in a New York industry
- Strong command of style guides including AP, Chicago, or industry-specific standards
- Ability to collaborate with legal, compliance, or clinical teams on document review cycles
- Familiarity with version control workflows and document lifecycle management practices
Documentation Specialist Jobs in New York: Frequently Asked Questions
How do you become a documentation specialist in New York?
Most documentation specialist roles in New York require a bachelor's degree in English, communications, technical writing, or a field related to the industry you are targeting. There is no state-issued license specific to documentation specialists in New York, but industry credentials such as the Certified Professional Technical Communicator designation from the Society for Technical Communication are recognized by many New York employers and strengthen candidacy, particularly in regulated sectors like finance, healthcare, and pharmaceuticals.
Which companies hire documentation specialists in New York?
Employers hiring documentation specialists in New York right now include Catholic Health, Catholic Health System, and M&T Bank, based on current listings on Migrate Mate as of June 2026. New York's dense concentration of financial institutions, hospital systems, and life sciences companies means steady, year-round demand for documentation professionals with regulatory and compliance experience.
Which New York cities have the most documentation specialist jobs?
Albany, Buffalo, and Getzville have the most documentation specialist openings in New York. New York City leads by volume because of its concentration of major financial institutions, law firms, and healthcare networks, while Albany draws demand from state government agencies and regulatory bodies, and Buffalo's growing healthcare and manufacturing base supports consistent documentation hiring in those sectors.
Are there remote documentation specialist jobs in New York?
Yes, and more than most fields. Documentation specialist work is largely desk-based and output-driven, making it well suited to remote and hybrid arrangements. About 50% of documentation specialist openings tied to New York are remote or hybrid as of June 2026, reflecting how broadly employers in finance, technology, and pharmaceuticals have adopted flexible work models for this role. Regulatory and compliance documentation roles tend to offer the most remote flexibility.
How can I get hired as a documentation specialist in New York with little or no experience?
The most realistic entry path is applying for documentation coordinator or records associate roles, which New York hospital systems like NYU Langone and Northwell Health and large financial firms post as on-ramps that require no prior specialist experience. Building a portfolio of writing samples, SOPs, or process documents from academic or volunteer work gives candidates a concrete edge. Adjacent roles in administrative coordination, legal filing, or editorial assistance at New York publishing houses or media companies are also recognized as qualifying experience by many New York employers.
Where can I find and apply to documentation specialist jobs in New York?
You can find and apply to documentation specialist jobs in New York on Migrate Mate, which lists current New York openings updated regularly. Find roles that fit your background and apply directly to the ones that match.
See All 10 Documentation Specialist Jobs in New York
Find roles in New York that match your experience and apply in just a few clicks.
Find Documentation Specialist Jobs